Migraine Pain Linked to Stress Varies by Individual

PainRelief.com Interview with:

Serena L. Orr, MD, MSc, FRCPC, FAHS
Assistant Professor
Depts of Pediatrics, Clinical Neurosciences and Community Health Sciences 
Cumming School of Medicine, University of Calgary
Director, Pediatric Headache Program
Alberta Children’s Hospital

Dr. Orr

PainRelief.com:  What is the background for this study?

Response: Stress has long been felt to be one of the most common trigger factors for migraine. However, there is very little data on the relationship between stress and pain severity in individuals with migraine on a day-to-day basis, and this relationship is even more poorly understood among individuals with more frequent attacks, such as those with chronic migraine (who have at least 15 days/month of headache, 8 or more of which meet criteria for migraine attacks).

This was a study that looked at daily electronic headache diary data for 136 adults with chronic migraine, using data from the N1-Headache application. In this study, we aimed to understand the relationship between perceived stress and pain severity in individuals with chronic migraine. Individuals completed 90 days of daily diary entries where they reported on their headache characteristics, and their perceived stress levels, measured on a scale of 0-10.

PainRelief.com: What are the main findings?

Response: The main findings were that individuals with chronic migraine report different patterns of peak pain severity from day-to-day, with 13.2% reporting mild pain severity on the majority (>50%) of days, 47.1% reporting moderate pain severity on the majority of days, and 10.3% reporting severe pain severity on the majority of their days; the remaining participants (29.4%) reported more variable patterns of pain severity from day-to-day.

With regards to the relationship between pain severity and perceived stress, we tested this in models that adjusted for other important variables like sex, age, menstrual bleeding status, day of the week, presence of continuous headache, and disability level. In these models, there was a positive association between pain severity and perceived stress, with the odds of higher pain severity increasing by 10% for each additional point on the perceived stress scale.

However, when we looked at the variability from individual-to-individual, we saw that there were significant differences between individuals in their stress-pain severity relationship (as reflected in significant random slope and intercept in the model). While most individuals had higher pain severity with higher perceived stress, some showed no significant relationship between the two, and some had an inverse relationship, where pain severity was lower on days of higher perceived stress

PainRelief.com: What should readers take away from your report?

Response: The main messages here are that:

1) The pain experience differs from individual-to-individual in those with chronic migraine from a severity perspective, and

2) Though most individuals with chronic migraine show a positive association between pain severity and perceived stress, this is not universal. Each individual has their own unique pattern, with some showing higher pain severity on days where perceived stress is high, and some showing the opposite relationship or no relationship.

This becomes important to understand at an individual level, so that people with chronic migraine can understand their own pattern and tailor treatment accordingly. For example, someone with a strong relationship between higher perceived stress and higher pain severity may want to invest more time in stress management and relaxation training than someone who does not show this relationship.

PainRelief.com: What recommendations do you have for future research as a result of this work?

Response: Because this is the first large, prospective study to look at the day-to-day relationship between pain severity and perceived stress in individuals with chronic migraine, the results need to be replicated. Ideally, the next study would used a validated perceived stress measure, as opposed to the 0-10 scale that we used in this study, which we presume reflects perceived stress, but has not been previously validated.

It would also be interesting to look at whether an individual’s pattern of pain severity in relation to perceived stress can predict treatment response to behavioral and psychological treatments. For example, would an individual with a strong stress-pain severity relationship be more likely to benefit from relaxation training or biofeedback than an individual without a strong relationship between these variables? This would be an important contribution towards achieving personalized medicine for individuals with chronic migraine, where the treatment is prescribed in relation to the individual’s personal profile.

PainRelief.com: Is there anything else you would like to add?

Response: It’s exciting to see studies like this one come to fruition, where we use detailed daily clinical data to understand individual patterns in people with migraine. This is made possible by work with electronic diary data, such as N1-Headache, that allows us to better understand migraine on an individual level, rather than assuming that all individuals have the same experience of migraine.

Regarding disclosures, I receive royalties for book publication from Cambridge University Press. I receive research funding from the Canadian Institutes of Health Research and the Alberta Children’s Hospital Research Institute. I am also an associate editor of Headache. I do not believe that any of these disclosures pertain specifically to this work.


Vives-Mestres M, Casanova A, Hershey AD, Orr SL. Perceived stress and pain severity in individuals with chronic migraine: a longitudinal cohort study using daily prospective diary data. Headache 2021;epub;DOI: 10.1111/head.14199.

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